Wednesday, July 30, 2014

Mark Twain and Health Reform

It’s not as bad as it sounds

Mark Twain (1835-1910), speaking of Richard Wagner’s music

Last night I was watching a PBS documentary on Mark Twain by Ken Burns on PBS . I was struck by Twain’s humor, worldliness, pride in America, racial tolerance, and grasp of how grass roots Americans think.

I got to thinking about what he would say about health reform. I went looking for Twain quotes that might apply to health reform and ObamaCare, and I came up with these.

• There’s a million in it!
In our day, it’s more like $3 trillion.

One of the brightest gems of New England weather is the uncertainty of it. Ditto, ObamaCare weather. It’s hot and cold with gusts of wind. But it's not the heat, it's the humility.

• The Child of Calamity!
Otherwise known as unintended consequences, such as 1 in 5 Americans deciding not to have any health plans at all. They have decided they're too costly.

I said I didn’t know. Obama’s stock answer when he learns of an unexpected scandal, “ I didn’t know. I learned it on the news.”

All the modern inconveniences. Such as coping with ACA rules and regulations and unexpectedly high premiums

When angry, count four, when very angry, swear. When very, very angry, vote.

Nothing so needs reforming as other people’s habits. Individuals in a Democracy are stubborn. They don’t want government mandating what they should do and not do and why and what they should pay and otherwise tinkering with their freedom.

Put all your eggs in one basket and – and watch that basket. The basket is known as the one-size-fits-all basket which contains all the services you or others might theoretically need.

• Noise proves nothing. Often a hen who merely laid an egg cackles as iif she had laid an asteroid.
Obama may have laid an egg, and no amount of cackle or crackle will make it into an omelette.

• Laws are sand, customs are rock.
Culture shapes our health system engine, throwing sand in the gears doesn’t make it run better.

• It is a difference of opinion that makes for horse racing.
And Senate races.

I could do it as easy as falling off a log. ObamaCare is not a log.

• The report of my death is an exaggeration.
So is the death of ObamaCare.

Familiarity breeds contempt and children. And frustrations with

All kings are rapscallions. That goes for politicians, too.

• All I know is that man is a human being – that is good enough for me.
And it is good enough for the uninsured and the middle class.

• When it doubt, tell the truth.
Sometimes that’s hard when you’ve broken your major promises about keeping your doctor and health plan and lowering premiums.

• Be good and you will be lonely; be good and you will be eccentric.
It’s easy to be good when you’re spending other peoples’ money, but you may end up lonely and eccentric.

• I have been reading the morning paper. I do it every morning - well knowing that I shall find in it the usual depravities and basenesses and hypocrisies and cruelties that make up civilization.
Welcome to the health care debate.

• I have had a “call” to literature, of a low order- i.e.humor. It is nothing to be proud of, seriously scribbling to excite the laughter of God’s creatures.
It is sad to say, but there is nothing funny to be said about ObamaCare.

Tuesday, July 29, 2014

Obama Impeachment as Fundraising Tactic

Dems Can’t Stop Talking About Impeaching President Obama

Mike Lillis, title of article in The Hill, July 29, 2014

Think about it, threat of impeachment,
Is heaven made for demagogic preachment.

Boehner may call impeachment talk a "scam".
But to Dems, it’s verbal battering ram.

You can call Obama’s critics racists,
You can even call them Tea Party fascists.

When Boehner proposes to sue the President,
Dems know what he has in mind isn’t pleasant.

The prez says, go ahead: sue me, impeach me.
He knows odds for success will not come to be.

Besides, in the land of Obama milk and honey,
Talk of impeachment raises gobs of money.

And if the President is expert at anything,
He's an expert on the fund raising thing.

Corporate America and Health Reform

The best we get from government in the welfare states is competent mediocrity. What is impressive is the administrative incompetence. Every country reports the same confusion, the same lack of performance, the same proliferation of agencies, of programs, of forms, and the same triumph of accounts rules over results.

Peter F. Drucker, (1909-2006), father of modern management, social philsopher, and conservative economist

With ObamaCare, corporate America is up against it.

They are being asked to cover all workers if they have over 50 employees or pay a stiff fine.

They are being asked to offer often unaffordable same-size-fits-all plans covering 10 essential benefits to all workers whether their employees need these benefits or not.

They are being asked to carry the load for over 150 million workers, while being taxed at the highest corporate tax in the world 39%, while the average corporate tax for the rest of the developed world is 25%.

Corporate Options

What are the corporate options?

• They can offer wellness programs and bonuses for workers who participate or who have measurable health improvements. Most major companies are doing this, but they are running up against employee resistance. People do not like being told how much they should exercise, eat, drink, smoke or weigh, or how large their waistlines should be. Those are private matters. Americans are increasingly resisting private surveillance and intrusions into their private lives and calls for behavioral changes.

• They can hire in-house doctors, pay companies who offer these services on an ad hoc basis, or set up worksite clinics. These are fine ideas, best suited for large companies with enough employees and enough scale to make these options work. Through these options, they can hire nurses and doctors to teach preventive care, provide care at the workplace, pick effective low-cost specialists.

• They can offer and encourage Health Aavings Accounts (HSAs) plans as the only or the preferred option to traditional PPOs and HMOs. This opyin shifts choice and costs to workers, who now have the incentive and responsibility of choosing their own doctors, negotiating on the basis of price and quality, taking better care of their health, and putting aside money in savings accounts for a rainy day and retirement. It is a powerful option and is catching on fast among employers and employees alike because of cost savings for business and lower premiums for workers.

• They can set up private exchanges to manage the costs for retirees and dependents. This is now being actively pursued by large corporations with an aging work force.

• They can directly contract and directly pay for certain health care services with retention payments for concierge practitioners and for commonly performed ambulatory surguries independent of third party involvement. This movement is in its infancy. But 3rd party administrative takes as much of 40% of the health care dollar. By bypassing 3rd party bureaucracies , be they governmental or private, companies and private individuals saves enormous amounts of money, but there are concerns about assuring quality of services being offered, the health outcomes of patient receiving these services, jurisdictional conflicts with health plans and hospitals, and short circuiting of government social policies.
Medicare- for-All

For every complex problem there is an answer that is clear, simple, and wrong.

Henry Mencken (1880-1956)

With 99 days to go before the midterms, when the fate of ObamaCare may be decided, people are debating how best to cover the uninsured.

I’ve been talking to three Democratic internist friends, contemporaries of mine, about ObamaCare prospects and they all say the answer is simple: Medicare-for-all.

Medicare-for-all is a simple, direct, and compellingly attractive answer. Medicare has worked for 50 years. People like it. It reeks of compassion.

Above all, Medicare-for-all would remove, minimize, or control those profit-mongers - drug companies, device-makers, business-men of every ilk, those proponents of capitalism -from the medical-industrial- complex. Business and medicine don’t mix. Never mind that profit is the life-blood of capitalism and socialism, for that matter. Without profit, social programs are not feasible. Don't sweat the details. Regulate the hell out of those greedy business bastards. That is the answer.

In any event, Medicare-for- all assigns clear responsibility to government. No one need worry anymore about who pays for care. Big Brother does. We all do. It is health care utopia – one for all, all for one, and everything for everybody, within rationing limits of course.

There is one problem - with the aging population, life-spans soon stretching to over 90, governmental managerial bureaucratic inefficiencies and perpetual cost overruns- Medicare-for-all is unsustainable. Even in its present form, Medicare is the largest and fastest growing share of the national budget. It will be consuming 20% of it by 2050. Compare that to the 4.4% now spent on the military.

Even now, Medicare does not have the managerial skills to implement a Medicare-for-all program – it has to outsource care. Just this week, Congress reached a deal to spend $10 billion to cut waiting times for Veterans in the VA by outsourcing care to the private sector. Think of The VA as a single payer microcosm of Medicare-for-all. The appetite of government for more money as a solution never ends.

In my conversations with my three internist friends, they all said they admired the late Arnold Relman, MD, who died last week at age 91.

Now there was a visionary of Medicare-for-all. As editor of thee New England Journal of Medicine Relman advocated single-payer by putting doctors on salary in large integrated groups and removing the profit motive from medicine.

Separating medicine from business is not so easy. Hospitals, which are businesses, make up 30% of health spending, and are the largest businesses and biggest employers in most cities. Health care hires 10% of Americans. Physician services comprises 10% of tax revenues for most states. Businesses offer health coverages for 156 million Americans. Business-minded entrepreneurs and innovators develop the medical devices and drugs that advance medicine. Health plans are mostly for-profit businesses that must satisfy investors.

So much for the health care-business quandary. Relman was an articulate powerhouse in presenting his point of view. In a moving tribute to Relman in the July 24 New England Journal of Medicine, the Journal’s president editors had this to say.

“Between 1977, when he assumed the role of editor of the Journal, and 1991, when he retired from that position, Bud wrote more than 100 editorials on a wide range of topics. His writing style was lucid and direct, and he framed his arguments with great clarity of thought. “

“He was a master in the use of the bully pulpit, and he wrote passionately about many aspects of health care, especially voicing his unshakable opposition to the intrusion of business interests into the practice of medicine. He fought against commercialism and the rise of for-profit hospital systems. His views on health care, particularly his support for a single-payer health insurance system, were often controversial, and at times he became a lightning rod. He gave testimony on health care on Capitol Hill and spoke in many other venues, always with confident determination. Though his opinions often came under attack, he successfully prodded the health care community in an ongoing national debate about our health care system, the likes of which had never occurred before.”

Arnold Relman, RIP. Like my internist friends , I admired Relman. But in my view, he was an impractical idealist, caught up in a single-payer dream that will never die even though it has been debated, deflated, and defeated for over 100 years.

Monday, July 28, 2014

VA Deal Reached

See how the World rewards its Veterans!

Alexander Pope (1688-1744), Moral Essay

Just when it seemed the do-nothing Congress we do nothing, it did something. Just before its five week August recess, which will be devoted on how to prepare for the midterms, it reached agreement on a $17 million deal on how to clean up the VA mess.

The mess plaguing the 1000 hospital and clinic system were the unconscionable wait times for veterans to see a doctor, during which 1000 or so are said to have died. All told, 46,000 waited more than 3 months to be seen, and 7,000 were never seen after they applied. It was generally agreed that once they were seen, they received excellent care.

Of the $17 million, $10 million will go to being seen by private doctors outside the system, especially for veterans living more than 40 miles away from a VA facility; $5 million will be appropriated to hire new doctors, nurses, and other health care personnel; $1.5 billion will go for leasing 27 new clinics; and an unspecified amount will be spent for scholarships for veterans and for loans for in state tuition.
ObamaCare: The Big Bet

Put your money down, and place your bet.

Casino expression

In retrospect, it seemed like a good bet.

Health costs were rising. People were unemployed. Money was tight. They didn’t have money to spend on health care. You controlled all three branches of government. Fifty million people were uninsured.

Why not invest trillions in a nation-saving stimulus program, including a million or so for electronic health records? Why not pass a trillion dollar health reform program? The country needed your programs. You were the country’s transformational savior. You needed a big bang to cement your legacy in the pantheon of presidents.

So what if Republicans en masse opposed you. So what if the states opposed your reform proposals for Medicare. Just tell the states if they didn’t set up exchanges, they would get no tax credits and they would have to pay for the other states. That was his chief adviser, Jonathon Gruber’s , spin on what happened.

To hell with the Republicans and the Red states. It was full speed ahead.

Anyway, using federal largess to covering the uninsured was a noble idea. But as Samuel Johnson (1709-1785) once reminded us, “The road to hell is paved with good intentions.”

ObamaCare was and is a huge gamble. As Michael Barone points out: “Obama Democrats Lose Their Big Bet on Health Health Exchanges, “ Washington Times, July 25, 2014”.

“Under previous court decisions, Congress couldn't force state governments to administer federal laws. So congressional Democrats, seeking to muscle states into creating their own health insurance exchanges, chose to provide subsidies only for those states. Those opting for the federal exchange would have to explain to voters why they weren't getting subsidies.”

But this bet to muscle the states failed. By August 2011, only 10 states had created their own exchanges, and 17 states explicitly refused to do so. Health and Human Services Secretary Kathleen Sebelius kept extending deadlines to force states to create their own exchanges. The Supreme Court complicated things in 2012, by ruling government couldn't force states to pay for Medicaid expansion.

“Congressional Democrats and the Obama administration bet that they could force the states to do their will. When they lost their bet, the administration ignored the Constitution and ordered the spending of monies that Congress never authorized.”

“This,” said Barone, ” was lawless behavior, and reckless as well. It promised to individuals acting in reliance on government regulations money that was subject to being clawed back if a court applied the statute as written.”

Why did the bet fail? For several reasons.

• ObamaCare was unpopular from the onset by double digit margin, at this writing by 59% to 38%. People didn’t like being mandated to buy insurance. Employers didn’t like being told to cover employees or pay stiff fines of $3000 for each uncovered worker if they had over 50 employees. Religion minded corporations resented being forced to pay for contraceptives. Citizens didn’t like sharp increases in premiums to pay for benefits they didn’t need and to pay for the care of others.

• To the shock of the administration, people preferred local marketplace care to heavily regulated “free” government care. They disliked bureaucratic delays and restrictions and lack of access to local hospitals and long time doctors, which they had been promised they could keep.

• People began to have questions about the competence of government (58% in recent polls say the Obama administration is “incompetent”). This perception stems in part from the recent botched launch, the multiple delays in implementing ACA provisions, and the waivers being granted to, among others, congressional staffs, unions, and political friends.

• Critics began to level charges whether it was legal for government to spend trillions of dollars for things never authorized by Congress , as required by the Constitution. And they began to ask, why doesn’t the administration enforce the law as written, namely, only the states, not the federal government, can provide subsidies. The ObamaCare bet wasn't helped when it was learned that one of its chief architects, Jonathon Gruber, an MIT economist, revealed that he and the administration intended from the beginning to have only states pay for subsidies ("ObamCare's Insider Testimony: An Architect of the Health Law Backs Up Critics," WSJ, July 25, 2014).

The bottom line of the big bet: Obama succeeded in expanding government, but in the process, he has discredited big government. A lost bet may discourage future massive expansion of federal programs that require, as most do, matching spending by the states and approval by Congress and the Supreme court .

In the end, the owners of the national casino, American voters, will have to decide what the rules of the house are.